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Transfers from LTPAC facilities to Acute care facilities. We answered some of the questions of the steps, and updated as follows:
- Referral to ED
- This is a notification, not a request. We will need to be careful to describe edge cases where ED cannot take the patient (re-routing, etc.)
- Starting set of the data needed from SNF to ED from Partners Healthcare
- Discharge from ED back to SNF
- Notification, with a summary of what happened in the ED - close the loop outcome
- Transfer to Hospital admission
- Notification from ED/Hospital to SNF
- Response from SNF to Hospital with additional information
- Can we keep the referral ID? Should we call it something else?
- Determination whether the patient will be discharged to the same SNF
- Can be due to timing - whether the patient bed can stay on hold for time necessary to be at the hospital - possibly a notification from SNF to hospital
- Patient may decide to look for a different facility - notification form hospital to SNF
- Patient Discharge - close the loop. Whether they go to the same SNF or another, follow the 360XL process of request, select, transfer
- Which identifier? Use two?
We need a diagram for this, any volunteers?
There are some existing transactions: https://pathway-interact.com/ - we will review in two weeks.